Prevention Book


Human Trafficking

Aka: Human Trafficking, Human Sex Trafficking, Sex Trafficking, Forced Labor, Sexual Slavery, Slavery, Organ Trafficking
  1. Definition
    1. Human Trafficking
      1. Persons forced or coerced into exploitation (e.g. Forced Labor, Sexual Slavery, Organ Trafficking)
  2. Epidemiology
    1. Affects more than 27 Million persons annually worldwide ($10-30 Billion global industry)
    2. U.N. estimates up to 20% of Kidney donors were coerced into organ donation via black market
    3. Affects at least 17,000 Immigrants brought to the United States annually
    4. Affects U.S. residents who are coerced into Forced Labor or Sexual Slavery (87% are <25 years old)
      1. Adult women: 46%
      2. Minor Girls: 21%
      3. Adult Males: 21%
      4. Minor Boys: 12%
      5. Shandro (2016) Ann Emerg Med 68(4): 501-8 [PubMed]
  3. Risk Factors
    1. Highest risk
      1. Physical, sexual or emotional abuse
      2. Runaway, Homelessness or living in shelter
        1. From 10-50% report survival sex to obtain food, shelter, drugs or money
    2. Other risk factors
      1. Foster care children
      2. Juvenile justice system offenders
      3. Disabled patients
      4. American Indian and Alaskan Native
      5. Decreased english proficiency
      6. LGBT patients (Lesbian, gay, bisexual, Transgender)
      7. Poverty
      8. Low education
      9. Substance Abuse or Chemical Dependency
      10. Delayed presentations for Prenatal Care
  4. Precautions
    1. Victims of Human Trafficking are most likely to be seen in health care, especially emergency departments
    2. Emergency Departments offer a unique opportunity for identifying and assisting Human Trafficking victims
      1. From 30 to 80% of Human Trafficking victims are seen at medical facilities
    3. Red Flags
      1. Companion (trafficker, may be male or female, and may truly be a close relative)
        1. Speaks on behalf of the patient (may be dominant, controlling)
        2. Does not wish to be separated from the patient
        3. Acts as Interpreter for patient
        4. Completes medical paperwork for the patient
      2. Patient
        1. Does not have identification (often confiscated by traffickers)
        2. History may be vague or inconsistent
        3. Language barriers may be present (use an official Medical Interpreter)
        4. May have multiple sex partners or prior arrests for prostitution
        5. Mental illness and Substance Abuse may be comorbid
          1. Depressed mood
          2. Anxiety Disorder
          3. Low self esteem
        6. Does not know local area, their home address, directions home
          1. May claim they just moved to area or just visiting
  5. History
    1. See HEADSS Screening (for adolescent and young adult history)
    2. Approach (Trauma informed care, with pearls from WHO)
      1. Build rapport with the patient and establish trust
      2. Treat in honest and nonjudgemental manner (empathy, not pity)
      3. Patient may not see themselves as a victim (and may resent the implication)
      4. Help patient feel that they are in a safe environment
      5. Recognize that patients may have coping mechanisms with maladaptive behaviors and difficult encounters
      6. Sit at eye level with patient
      7. Be aware of body language
      8. Avoid interrupting patient
      9. Avoid making un-keepable promises
      10. Avoid playing the role of friend or surrigate parent
      11. Avoid using technical words or derogatory terms (e.g. hooker)
      12. Disclose any mandatory reporting requirements when conducting interview
    3. Interview the patient without companions present (most important single measure)
      1. Obtain an independent, official Medical Interpreter
      2. May separate patient from companion during exam or diagnostics, or while companion completes forms
      3. Start with open ended questions and avoid leading questions
      4. Establish true age of patient (under age 16 or under age 18?)
      5. Crowded living and sleeping conditions?
      6. Adequate nutrition?
      7. Who are companions and do you trust them?
      8. Forced to work or have sex?
    4. Common presentations
      1. Vague presenting complaints
      2. Inconsistent medical history
      3. Recurrent Sexually Transmitted Infections or Pelvic Inflammatory Disease
      4. Recurrent Urinary Tract Infections
      5. Unwanted Pregnancy
      6. Dyspareunia
    5. Mental health conditions
      1. Anxiety Disorder
      2. Major Depression
      3. Post-Traumatic Stress Disorder
      4. Self Injury
      5. Substance Use Disorder
    6. Other associated conditions
      1. HIV Infection
      2. Hepatitis B
      3. Hepatitis C
  6. Signs
    1. General
      1. See Nonaccidental Trauma for signs of abuse (e.g. ligatures, Bruising, burns, bites, scars)
      2. Signs of injury not consistent with history
      3. Malnourished or dehydrated
      4. Poor Dentition
      5. Growth retardation or Developmental Delay in children
      6. Tattoos that function as a traffickers brand of ownership (may include numbers, letters)
      7. Retained material in vagina such as cotton sponges (used to hide Menses)
      8. Vaginal Trauma
      9. Inappropriate Dress
      10. Signs of drug use, Substance Abuse or Intoxication
    2. Affect and behavior
      1. May be irritable, anxious, aggressive
      2. May have flat affect, detached or make poor eye contact
      3. May fear involving law enforcement
      4. May have self-inflicted injuries (e.g. cutting)
  7. Management
    1. Stabilize acute medical conditions and address the chief compliant
    2. Patient must give permission to proceed with each step of the evaluation
      1. Evaluation of Child Abuse or Child Sexual Abuse should follow local protocols (including reporting)
    3. Staff chaperone or victim advocate should acompany the patient
    4. Sexual Assault (see SANE Nurse below)
      1. Perform Sexually Transmitted Infection testing (HIV, Hepatitis B, Syphilis)
      2. Offer Emergency Contraception
      3. Offer Post-exposure Prophylaxis (GC, Chlamydia, Trichomonas, HIV PEP, Hepatitis B)
    5. Consultation
      1. National Human Trafficking Hotline (see below)
        1. Clinicians should consider calling for practical advice in suspected trafficking cases
      2. Hospital Security
        1. Notify early regarding concerns for safety of both the patient and staff
      3. Forensic nurses (SANE nurses) Indications (urgent evaluation in Emergency Department)
        1. See Sexual Assault
        2. Acute Sexual Assault within prior 120 hours
        3. Sexually Transmitted Infection symptoms or other medically urgent complaints
        4. Anogenital Trauma or other suspicious injuries requiring forensic documentation
        5. Child with mental health or safety concerns
      4. Medical Interpreter
        1. Allows a detailed, reliable careful history
        2. Avoid translation by companions
      5. Survivor-centered protocols
        1. Social workers
        2. Crisis organizations
        3. Shelters
        4. Law enforcement
        5. Mental health and Chemical Dependency treatment
    6. Legal concerns
      1. Follow mandatory reporting protocols (e.g. Child Abuse)
        1. If not mandated by law, patient has the right to refuse law enforcement and other notification
      2. Undocumented Immigrants may obtain T Visa (trafficking Visa) in some cases
        1. Allows trafficking victims to safely remain in U.S. legally
      3. Several laws protect victims of Human Trafficking
        2. Trafficking Victims Protection Act (TVPA)
        3. Justice for Victims of Trafficking Act (JVTA)
        4. Child Abuse Prevention and Treatment Act (CAPTA)
        5. Preventing Sex Trafficking and Strengthening Families Act
    7. Documentation
      1. Document suspected Human Trafficking and related findings
    8. Follow-up
      1. Often difficult if continues under control of human trafficker
      2. Scheduling follow-up will increase contact and build rapport
      3. Consider hospital admission for serious illness or injury that requires close follow-up
      4. Reevaluate in 2 weeks for pregnancy, Sexually Transmitted Infection, injuries
  8. Resources
    1. National Human Trafficking Hotline
      2. Phone: 1-888-373-7888
      3. Text "HELP" to 233733 (BeFree)
      4. Online website also has a chat
    2. Polaris Project
    3. Wikipedia
    4. TraffickFree
    5. U.S. Laws on Human Trafficking (U.S. State Department)
  9. References
    1. Jhun, Weinstock and Flores in Herbert (2015) EM:Rap 15(7): 7
    2. Roszcynialski, Irvine and Walter (2018) Crit Dec Emerg Med 32(12): 3-10
    3. Swadron, Weinstock, Downing and Kaiser in Herbert (2015) EM:Rap 15(7): 8-9
    4. Becker (2015) Pediatr Emerg Care 31(2): 144-7 [PubMed]
    5. Patel (2010) West J Emerg Med 11(5): 402-4 [PubMed]
    6. Suniega (2022) Am Fam Physician 105(5): 521-8 [PubMed]

Slavery (C3658278)

Definition (MSH) The status or condition of a person over whom any or all of the powers attaching to the right of ownership are exercised. The slave trade is all acts involved in the capture, acquisition or disposal of persons with intent to reduce them to enslavement; all acts involved in the acquisition of enslaved persons with a view to selling or exchanging them; all acts of disposal by sale or exchange of persons acquired with a view to being sold or exchanged, and, in general, every act of trade or transport of slaves. ( from accessed 10/18/2012)
Concepts Social Behavior (T054)
MSH D063947
English Slaveholdings, Slavery, Enslavement, Slaveholding, Enslavements
Czech otroctví
French Possession d'esclaves, Asservissement, Esclavage, Assujettissement, Détention d'esclaves
German Sklavenhalterei, Versklavung, Sklaverei
Italian Detenzione di schiavi, Riduzione in schiavitù, Schiavitù
Norwegian Slaveri, Slavebinde, Slavehold, Slavebinding
Derived from the NIH UMLS (Unified Medical Language System)

Organ Trafficking (C3658318)

Definition (MSH) Criminal activity that occurs in three broad categories. Firstly, cases where traffickers force or deceive the victims into giving up an organ. Secondly, there are cases where victims formally or informally agree to sell an organ and are cheated because they are not paid for the organ or are paid less than the promised price. Thirdly, vulnerable persons are treated for an ailment, which may or may not exist and thereupon organs are removed without the victim's knowledge.
Concepts Human-caused Phenomenon or Process (T068)
MSH D064877
English Traffickings, Organ, Organ Trafficking, Organ Traffickings, Trafficking, Organ
Czech obchodování s lidskými orgány, obchodování s orgány
French Trafic d'organes
German Organhandel
Italian Traffico di organi
Norwegian Kriminell organhandel
Derived from the NIH UMLS (Unified Medical Language System)

Human Trafficking (C3658341)

Definition (MSH) Recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. (UN. Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. General Assembly resolution 55/25. United Nations General Assembly, 2000)
Concepts Human-caused Phenomenon or Process (T068)
MSH D064410
English Human Traffickings, Traffickings, Human, Trafficking, Human, Human Trafficking
Czech obchod s lidmi, obchod s bílým masem
French Trafic d'êtres humains, Trafic des êtres humains, Traite d'êtres humains, Traite des êtres humains
German Menschenhandel
Italian Traffico di esseri umani, Tratta di persone, Tratta di esseri umani
Norwegian Menneskehandel
Derived from the NIH UMLS (Unified Medical Language System)

Sex Trafficking (C3661464)

Definition (MSH) Traffic in women and children, in particular for the purpose of sexual exploitation.
Concepts Social Behavior (T054)
MSH D064410
English Sex Trafficking, Trafficking, Sex, Sex Traffickings
Czech obchod se sexem, obchod se sexuálními službami
French Trafic sexuel, Traite sexuelle
German Zwangsprostitution
Italian Traffico sessuale, Tratta a sfondo sessuale, Traffico di sesso, Tratta sessuale
Norwegian Sexhandel og -utnyttelse, Salg av kvinner og barn til seksuell utnyttelse, Sexhandel og utnyttelse
Derived from the NIH UMLS (Unified Medical Language System)

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